1) Vitamin D For Chronic Pain - Pain Treatment Topics.org

More documents

Recommendations

Info

Vitamin D for Chronic Pain more critical factor. Taking 10,000 IU of D 3 daily for six months has been implicated as toxic, 22,132 whereas Holick [2007] 14 noted that this daily amount in adults can be well tolerated for five months. And, this 10,000 IU/day dose was used successfully and safely during three months in one study for relieving back pain. 74 Vieth et al 100 demonstrated that 4000 IU of D 3 per day was well tolerated during 15 months of therapy. Concentrations of 25(OH)D were increased to more optimal levels and parathyroid hormone was reduced, while calcium levels remained normal. Some researchers have proposed that long-term daily consumption of 40,000 IU of vitamin D would be needed to cause hypercalcemia. 18,19 The US Office of Dietary Supplements 133 notes that hypercalcemia can result from 50,000 IU/day or more taken for an extended period of time. There have not been any reports in the literature of a single, one-time excessive dose of vitamin D (D 2 or D 3 ) being toxic or fatal in humans. However, a number of incident reports of vitamin D toxicity involving very high doses, and including 6 fatalities, have appeared in the literature. In the incident reports, encompassing 77 cases of toxicity, amounts of vitamin D taken for periods ranging from days to years included daily doses from 160,000 IU up to an astounding 2.6 million IU. 125,126,128,129,130,131,134,135 The relatively few fatalities resulted from secondary causes during treatment for hypercalcemia. A common feature of all incidents was that victims were not knowingly or intentionally taking excessive amounts of vitamin D, and no one was taking vitamin D under practitioner supervision. In almost all cases, toxic overdoses could have been avoided with better quality control in product manufacture and/or education of patients in the proper use of supplements. As another measure of safety, consolidated data for 2006 were examined (the most recently reported year) from 61 poison control centers serving 300 million persons in the United States. 136 There were only 516 mentions of incidents involving vitamin D which, by comparison, were roughly one-fourth the number for vitamin C and merely 0.8% of all incidents involving vitamin products. Only 13% of all vitamin D cases required treatment in a healthcare facility, although adverse signs/symptoms were absent or minimal in almost all patients (92%). Only 5 of the victims had more pronounced signs/symptoms of vitamin D toxicity, but these were not life threatening and there were no serious adverse events reported. Vitamin D-Drug Interactions There have been relatively few mentions in the literature of vitamin D supplements interacting with other agents or medications, and these are summarized in Table 7. In most cases, the potency of vitamin D is reduced by the other drug and the vitamin dose can be increased to accommodate this. Conversely, very high doses of vitamin D should be avoided due to possible risks of hypercalcemia when taken with digitalis/digoxin or certain diuretics. Additionally, St. John’s wort, 27 excessive alcohol, 133 and tobacco smoking 138 have been reported to potentially reduce the effects of vitamin D. Mineral oil and stimulant laxatives decrease dietary calcium absorption and can influence hypocalcemia. 133 Gastric bypass and other gastric or intestinal resection procedures have been associated with vitamin D insufficiency. 60,106 It should be noted that not all patients would be affected by these interactions or effects, and vitamin D has not been noted TABLE 6. Signs/Symptoms of D Toxicity (Hypercalcemia) • abdominal pain • achy muscles/joints • anorexia • azotemia • calcifications • constipation • disorientation/confusion • fatigue/lethargy • fever/chills • GI upset • hypertension • muscle weakness • nausea • nervousness • polyuria • proteinuria • pruritus • excessive thirst • urinary casts • vomiting • weight loss References: Barrueto et al 125 ; Blank et al 126 ; Calcitriol 12 ; Carroll and Schade 127 ; Ergocalciferol 13 ; Johnson 20 ; Klontz and Acheson 128 ; Koutkia et al 129 ; Todd et al 130 ; Vieth et al 131 to interfere harmfully with the actions of any medications. Therefore, none of the reported interactions or effects has been indicated in the literature as a contraindication for vitamin D supplementation. Conclusions Extensive clinical evidence and expert commentary supports the opinion that recommending adequate vitamin D intake for helping patients with chronic musculoskeletal pain and fatigue syndromes should be more widely recognized and acted upon. In many cases, contributing factors are nonspecific or undetermined. Even in cases where a specific etiology has been diagnosed, the potential for vitamin D deficit as a factor contributing to and/or prolonging the pain condition should not be ruled out. Further clinical research studies would be helpful. Vitamin D is not proposed as a “cure” for all chronic pain conditions or in all patients. Optimal clinical outcomes of vitamin D therapy might be best attained via multicomponent treatment plans addressing many facets of health and pain relief. Therefore, vitamin D is not suggested as a replacement for any other approaches to pain management. To start, a conservative total daily supplementation of 2400 IU to 2800 IU of vitamin D 3 is proposed as potentially benefitting patients. Along with that, some patience is advised regarding expectations for improvements; it may require up to 9 months before maximum effects are realized. In some cases, other factors or undetected conditions may be contributing to a chronic pain condition that vitamin D supplementation alone cannot ameliorate. In sum, for patients with chronic musculoskeletal pain and related symptoms, supplemental vitamin D has a highly favorable benefit to cost ratio, with minimal, if any, risks. In all likelihood, it would do no harm and probably could do much good.■ Acknowledgments The author wishes to acknowledge and thank the following expert reviewers of the full research report for their helpful comments and assistance: Bruce Hollis, PhD; Michael F. Holick, MD, PhD; Seth I. Kaufman, MD; Lee A. Kral, PharmD, BCPS; Paul W. Lofholm, PharmD, FACA; N. Lee Smith, MD; James D. Toombs, MD; Winnie Dawson, RN, BSN, MA. Practical PAIN MANAGEMENT, July/August 2008 ©2008 PPM Communications, Inc. Reprinted with permission. 39
Vitamin D for Chronic Pain TABLE 7. Drugs Potentially Interacting with Vitamin D Potency of vitamin D is reduced. The vitamin dose can be increased to accommodate this. • antacids (aluminum- or magnesium-containing) • anticonvulsants (eg, carbamazepine) • antirejection meds (after organ transplant) • antiretrovirals(HIV/AIDS therapies) • barbiturates (eg, phenobarbital, phenytoin) • cholestyramine • colestipol • corticosteroids • glucocorticoids • hydroxychloroquine • rifampin Risk of hypercalcemia when taken concurrently. Very high doses of vitamin D should be avoided. • digitalis/digoxin • thiazide diuretics References: Bringhurst et al 137 ; Calcitriol 12 ; Ergocalciferol 13 ; Holick 14 ; Hollis et al 124 ; Marcus 15 ; Mascarenhas and Mobarhan 51 ; ODS 133 ; Turner et al 60 Disclosure The author reports no involvement in the nutritional supplement industry or any other conflicts of interest. Covidien/ Mallinckrodt, St. Louis, MO, as a sponsor of Pain Treatment Topics, provided educational funding support for the research report on Vitamin D but had no role in its conception or development. The sponsor has no vested interests in the nutritional supplement industry and is not a manufacturer or distributor of vitamin products. Stewart B. Leavitt, MA, PhD, is the founding Publisher/Editor of Pain Treatment Topics and has more than 25 years of experience in healthcare education and medical communications serving numerous government agencies and other organizations. He was educated in biomedical communications at the University of Illinois at Chicago College of Medicine and then served as a Commissioned Officer in the US Public Health Service at the National Institutes of Health. He went on to earn Masters and Doctorate degrees specializing in health/medical research and education at Northwestern University, Evanston, Illinois. He is a member of the American Academy of Pain Management and a founding member of the International Association for Pain & Chemical Dependency. References 1. Mohr SB, Garland CF, Gorham ED, Garland FC. The association between ultraviolet B irradiance, vitamin D status and incidence rates of type 1 diabetes in 51 regions worldwide. Diabetologia. Online publication ahead of print, June 12, 2008. 2. Ng K, Meyerhardt JA, Wu K, et al. Circulating 25-hydroxyvitamin D levels and survival in patients with colorectal cancer. J Clin Oncol. 2008. 26(18):2984-2991. 3. Giovannucci E, Liu Y, Hollis BW, Rimm EB. 25-hydroxyvitamin D and risk of myocardial infarction in men. Arch Int Med. 2008. 168(11):1174-1180. 4. APF (American Pain Foundation). Pain facts: overview of American pain surveys. 2007. Available online at: http://www.painfoundation.org/page.aspfile=Newsroom/ PainSurveys.htm. Accessed 2/25/08. 5. Nachemson A, Waddell G, Norlund A. Epidemiology of neck and back pain. In: Nachemson A, Jonsson E (eds) Neck and Back Pain: the Scientific Evidence of Causes, Diagnosis, and Treatment. Phila, PA: Williams & Wilkins; 2000: 165-188. 6. NPF (National Pain Foundation). Harris Interactive Survey on Pain in America, Dec 2007. Released in 2008. Avail at: http://www.nationalpainfoundation.org/ MyResearch/PainSurvey2008.asp. Accessed 2/25/08. 7. Watkins EA, Wollan PC, Melton III J, Yawn PB. A population in pain: report from the Olmsted County Health Study. Pain Med. 2008. 9(2):166-174. 8. Deyo RA. Diagnostic evaluation of LBP. Arch Intern Med. 2002. 162:1444-1448. 9. Deyo RA, Weinstein JN. Low back pain. New Eng J Med. 2001. 344:363-370. 10. Holick MF. Vitamin D for health and in chronic kidney disease. Semin Dial. 2005. 18:266-275. 11. Lau AH, How PP. The role of the pharmacist in the identification and management of secondary hyperparathyroidism. US Pharmacist. 2007(Jul):62-70. Avail at: http://www.uspharmacist.com/index.asppage=ce/105514/default.htm. Accessed 2/15/08. 12. Calcitriol. Merck Manual [online]. 2007. Avail at: http://www.merck.com/ mmpe/lexicomp/calcitriol.html. Accessed 2/19/08. 13. Ergocalciferol. Merck Manual [online]. 2007. Avail at: http://www.merck.com/ mmpe/lexicomp/ergocalciferol.html. Accessed 2/19/08. 14. Holick MF. Vitamin D deficiency. N Engl J Med. 2007. 357(3):266-281. 15. Marcus R. Agents affecting calcification and bone turnover: calcium, phosphate, parathyroid hormine, vitamin D, calcitonin, and other compounds. Chap 61. In: Hardman JG, Limbird LE, eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 9th ed. New York, NY: McGraw-Hill; 1995. 16. ODS (Office of Dietary Supplements; US National Institutes of Health). Dietary Supplement Fact Sheet: Vitamin D. Updated Feb 19, 2008. Avail at: http://dietarysupplements.info.nih.gov/ factsheets/vitamind.asp. Accessed 4/27/08 17. Singh YN. Vitamin D. Part I: Are we getting enough US Pharm. 2004a. 10:66-72. Avail at: http://www.uspharmacist.com/index.aspshow=article&page= 8_1352.htm. Accessed 4/29/08. 18. Tavera-Mendoza LE, White JH. Cell defenses and the sunshine vitamin. Scientific American. Nov 2007. Avail at: http://www.sciam.com/article.cfm id=celldefenses-and-the-sunshine-vitamin. Accessed 3/1/08. 19. Vieth R. The pharmacology of vitamin D, including fortification strategies. Chapter 61. In: Feldman D, Glorieux F, eds. Vitamin D. 2nd ed. Boston, MA: Elsevier Academic Press; 2005. Avail at: http://www.directms.org/pdf/VitDVieth/Vieth%20chapter %2061.pdf. Accessed 4/17/08. 20. Johnson LE. Vitamin D. Merck Manual [online]. 2007. Avail at: http://www.merck.com/mmpe/ sec01/ch004/ch004k.htmlqt=vitamin%20D&alt=sh#tb004_6. Accessed 2/19/08. 21. Lips P. Vitamin D deficiency and secondary hyperparathyroidism in the elderly: consequences for bone loss and fractures and therapeutic implications. Endocrine Rev. 2001. 22(4):477-501. 22. Reginster J-Y. The high prevalence of inadequate serum vitamin D levels and implications for bone health. Curr Med Res Opin. 2005. 21(4):579-585. Avail at: http://www.medscape.com/viewarticle/504783_ print. Accessed 2/24/08. 23. Holick MF, Biancuzzo RM, Chen TC, et al. Vitamin D2 is as effective as vitamin D3 in maintaining circulating concentrations of 25-hydroxyvitamin D. J Clin Endocrinol Metab. 2008. 93(3):677-687. 24. Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. Am J Clin Nutr. 1999. 69:842-856. 25. Hollis BW. Circulating 25-hydroxyvitamin D levels indicative of vitamin D sufficiency: implications for establishing a new effective dietary intake recommendation for vitamin D. J Nutr. 2005. 135:317-322. Available by search at: http://jn.nutrition.org/search.dtl. Accessed 4/2/08. 26. Vieth R, Chan P-CR, MacFarlane GD. Efficacy and safety of vitamin D3 intake exceeding the lowest observed adverse effect level. Am J Clin Nutr. 2001:73: 288-294. Avail at: http://www.ajcn.org/cgi/content/full/73/2/288. 27. Shinchuk L, Holick MF. Vitamin D and rehabilitation: improving functional outcomes. Nutr Clin Prac. 2007. 22(3):297-304. 28. Holick MF. Vitamin D: the underappreciated D-lightful hormone that is important for skeletal and cellular health. Curr Opin Endocrinol Diabetes. 2002b;9:87-98. 29. Holick MF, Chen TC. Vitamin D deficiency: a worldwide problem and health consequences. Am J Clin Nutr. 2008. 87(suppl):1080S-1086S. 30. Marshall TG. Vitamin D discovery outpaces FDA decision making. Bioessays. 2008. 30(2):173-182. 31. Walters MR. Newly identified actions of the vitamin D endocrine system. Endocrine Rev. 1992. 13(4):719-764. 32. Kawaguchi Y, Kanamori M, Ishihara H, et al. The association of lumbar disc disease and vitamin-D receptor gene polymorphism. J Bone Joint Surg Am. 2002. 84-A(11):2022-2028. 33. Videman T, Gibbons LE, Battie MC, et al. The relative roles of intragenic polymorphisms of the vitamin D receptor gene in lumbar spine degeneration and bone density. Spine. 2001. 26(3):A1-A6. 34. Grant WB. An estimate of premature cancer mortality in the U.S. due to inadequate doses of solar ultraviolet-B radiation. Cancer. 2002. 94:1867-1875. 35. Holick MF. Vitamin D: a millenium perspective. J Cell Biochem. 2003a. 88:296- 307. 36. Holick MF. Vitamin D: photobiology, metabolism, mechanism of action, and clinical applications. In: Favus MJ, ed. Primer on the Metabolic Bone Diseases and 40 Practical PAIN MANAGEMENT, July/August 2008 ©2008 PPM Communications, Inc. Reprinted with permission.
Page 1 and 2: VITAMIN D FOR CHRONIC PAIN Accordin
Page 3 and 4: Vitamin D for Chronic Pain TABLE 2:
Page 5 and 6: Vitamin D for Chronic Pain Practica
Page 7 and 8: Vitamin D for Chronic Pain study of
Page 9: Vitamin D for Chronic Pain TABLE 5.
Page 13: Vitamin D for Chronic Pain vitamin

1) Vitamin D For Chronic Pain - Pain Treatment Topics.org

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?